Provider Demographics
NPI:1720289358
Name:MEDERI CARETENDERS VS OF BROWARD, LLC
Entity Type:Organization
Organization Name:MEDERI CARETENDERS VS OF BROWARD, LLC
Other - Org Name:MEDERI CARETENDERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. V.P., ADMINISTRATION
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:LYLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-891-1044
Mailing Address - Street 1:9510 ORMSBY STATION RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-4081
Mailing Address - Country:US
Mailing Address - Phone:502-891-1000
Mailing Address - Fax:502-891-8067
Practice Address - Street 1:4723 W ATLANTIC AVE
Practice Address - Street 2:SUITE A13 & 14
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33445-3895
Practice Address - Country:US
Practice Address - Phone:561-381-1077
Practice Address - Fax:561-496-0357
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDERI CARETENDERS VS OF BROWARD, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-30
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107229Medicare Oscar/Certification